Nontraumatic Splenic Rupture

CASE REPORT

Nana Sefa, MD, MPH; Ananda V. Pandurangadu, MD; Amanda Mann, MD; Amit Bahl, MD, MPH

A 25-year-old man presented for evaluation of lightheadedness as well as pain in his left shoulder, epigastric region, and right flank.

Case pallor. His head, eyes, ears, nose, and throat; A 25-year-old college student presented to cardiac; pulmonary; and neurological ex- the ED following a near-syncopal episode. aminations were normal. The abdominal ex- The patient stated he had felt lightheaded amination revealed a soft, minimally tender and had fallen to his knees immediately af- epigastrium but with normal bowel sounds. ter taking a shower earlier that morning, but Initial laboratory studies were remarkable did not experience any loss of consciousness for low hemoglobin (Hgb; 12.0 g/dL) and or injury. He denied a history of syncope or elevated aspartate transaminase (105 U/L), any recent trauma or fatigue. A review of the alanine aminotransferase (168 U/L), total patient’s systems was negative. His medical bilirubin (1.6 mg/dL), and glucose (179 mg/ history was remarkable for irritable bowel dL) levels. The patient’s troponin I and li- syndrome; he had no surgical history. Re- pase levels were within normal range. An garding his social history, he admitted to oc- electrocardiogram was unremarkable. casional alcohol use but denied any tobacco Given the patient’s elevated hepatic en- or illicit drug use. He was not on any current zymes, right upper quadrant ultrasound was prescription or over-the-counter medica- obtained, which demonstrated a normal tions and denied any allergies. gallbladder, a moderate amount of compli- The patient’s initial vital signs at presen- cated free fluid (with hyper-echoic densities tation were: blood pressure, 112/58 mm suggestive of coagulated blood) in all four Hg; heart rate, 86 beats/min; temperature, quadrants, and splenomegaly measuring 97.9°F; and respiratory rate, 18 breaths/ 13.7 cm (Figure 1a and 1b). Based on the min. Oxygen saturation was 100% on ultrasound findings, an abdominal and pel- room air. The patient reported pain in his vic computed tomography (CT) scan with left shoulder, epigastric region, and right intravenous (IV) contrast was immediately flank. He rated his pain as a “4” on a 0-to- obtained, which revealed free fluid, a sen- 10 pain scale. tinel clot sign around the enlarged spleen On physical examination, the patient was measuring 15 cm, and a posterior splenic alert and oriented; he was thin and had mild laceration measuring 1 cm (Figure 2).

Dr Sefa is a resident, department of emergency medicine, Beaumont Health System, Royal Oak, Michigan. Dr Pandurangadu is an assistant professor, department of emergency medicine, Rush University, Chicago, Illinois. Dr Mann is a resident, department of emergency medicine, Henry Ford Hospital, Detroit, Michigan. Dr Bahl is a director of emergency ultrasound and ultrasound fellowship director, department of emergency medicine, Beaumont Health System, Royal Oak, Michigan. Authors’ Disclosure Statement: The authors report no actual or potential conflict of interest in relation to this article. DOI: 10.12788/emed.2016.0059

456 EMERGENCY MEDICINE I OCTOBER 2016 www.emed-journal.com A B

Figure 1. (A) Ultrasound of the patient’s right upper quadrant demonstrating free fluid in Morrison’s pouch white( arrow). (B) Ultrasound of the patient’s left upper quadrant demonstrating splenic hematoma (black arrow) and free fluid in the splenorenal recess white( arrow).

The patient’s status, including his vital signs, remained stable throughout his en- tire ED course. However, repeat laboratory studies taken 4 hours after initial evaluation revealed a further decrease of Hgb to 8.6 g/dL, for which the patient was given IV fluids and 2 U of packed red blood cells. He was admitted to the intensive care unit, where he continued to be managed nonoperatively. Over the next 2 days the patient remained stable and his Hgb trended up. Additional laboratory testing prior to dis- charge revealed the following results:

Positive: IIEpstein-Barr virus (EBV) IIViral capsid antigen (VCA) immunoglobulin G Figure 2. Computed tomography of the patient’s abdomen demonstrating splenic IIVCA immunoglobulin M laceration (black arrow) and free fluid in abdomen white( arrows). Negative: IIMononuclear spot test Discussion IIHuman immunodeficiency virus Although the spleen is the most common IIHepatitis B and C intra-abdominal organ that can rupture IIAntinuclear antibodies with blunt abdominal trauma, splenic IIVenereal disease research laboratory test rupture in the absence of trauma is very rare. Nontraumatic splenic rupture (NSR) The rest of the patient’s recovery was un- has been associated with pathological and eventful, and he was discharged home in nonpathological spleens.1,2 A systemic re- stable condition on hospital day 3. view of NSRs showed that 7% of the 845

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Table. Classification of Splenic Laceration Injury11

Grade Injury Type Injury Description Signs and Symptoms 1 Hematoma Subcapsular tear, nonexpanding, <10% Diagnosing NSR can be challenging and it surface area is often missed or discovered incidentally during evaluation (as was initially the case Laceration Capsular tear, nonbleeding, <1 cm with our patient).3 Several signs and symp- parenchymal depth toms present in our patient were red her- rings that warranted closer analysis. The 2 Hematoma Subcapsular tear, nonexpanding, 10%-50% surface area patient’s complaint of left shoulder pain suggested left hemidiaphragm irritation Intraparenchymal, nonexpanding, <5 cm diameter from the NSR. Furthermore, our patient’s near-syncopal episode was possibly due Laceration Capsular tear, active bleeding, 1-3 cm to acute vagal simulation from the initial parenchymal depth not involving a trabecular contact of blood with the peritoneal cavi- vessel ty.4 The maximal vagal stimulus was likely 3 Hematoma Subcapsular tear, >50% surface area or transient, as our patient returned to base- expanding line after a brief near-syncopal episode. Ruptured subcapsular tear, active bleeding As illustrated in our case, though tachy- Intraparenchymal hematoma, >5 cm cardia is common in splenic rupture, not or expanding all patients present with this sign. The absence of tachycardia in our patient can Laceration >3 cm parenchymal depth or involving be explained by the elevation of his base- trabecular vessels line enteric vagal tone due to the contin- Ruptured intraparenchymal hematoma, ued presence of blood in the peritoneum.5 4 Hematoma active bleeding There are also other factors associated with the absence of tachycardia. For example, a Laceration Laceration of segmental or hilar vessels producing major devascularization well-conditioned athlete presenting with (>25% of spleen) states of shock due to splenic rupture may not show signs of tachycardia.6 5 Laceration Completely shattered spleen

Vascular Hilar vascular injury that has San Francisco Syncope Rule devascularized spleen The San Francisco Syncope Rule (SFSR) is a clinical decision-making risk-strati- fication tool used to determine outcomes and disposition of ED patients presenting patients in the review had completely nor- with syncope.7 It is important to note that mal spleens; the remaining 93% had some if we had used a straightforward applica- form of splenic pathology.1 tion of the SFSR upon our patient’s initial presentation, the results would have been Etiology negative, suggesting he was not at risk for The top three causes of splenic enlarge- short-term serious outcomes.7 ment associated with NSR include hema- tologic malignancies, viral infections, and Imaging Studies inflammation.1,2 Although viruses, such As demonstrated in our patient, a quick as EBV and cytomegalovirus, represent point-of-care (POC) bedside ultrasound almost 15% of the pathological causes of scan can reveal the presence of free fluid NSR, it is not uncommon for a patient to in the abdomen to help with the diagnosis. have multiple pathological processes pres- On ultrasound, the presence of free fluid ent.1 Our patient’s enlarged spleen was due in the right upper quadrant is more com- to acute infectious mononucleosis. monly found in the hepatorenal recess,

458 EMERGENCY MEDICINE I OCTOBER 2016 www.emed-journal.com whereas in the left upper quadrant free flu- Nontraumatic splenic rupture is managed id is seen sub-diaphragmatic/suprasplenic nonoperatively or surgically based on the first before fluid is seen in the splenorenal grade of the injury as well as the patient’s recess. Bedside ultrasound can accurately hemodynamic status. Grades 1 and 2 are detect as little as 100 mL of free fluid in the managed mostly conservatively, whereas abdominal cavity, with a 90% sensitivity grades 4 and 5 are managed mostly opera- and 99% specificity.8 tively.12 A review of 845 cases from 1980 An ultrasound is highly sensitive as a to 2008 found that 14.7% were treated preliminary screening tool to identify the conservatively.1 Due to the immunosup- presence of free intraperitoneal fluid and pressive effects of splenectomy, there has has some limited utility in identifying any been a recent push toward conservative disruption in the splenic echotexture that treatment.12 may suggest a laceration or hematoma. Ul- trasound, however, has poor specificity in Conclusion identifying solid organ injuries.9 This case illustrates an uncommon pre- Computed tomography scanning is the sentation of NSR and underscores the imaging modality of choice for assessing importance of considering NSR in the splenic injuries, and should be obtained to differential diagnoses of patients present- confirm the presence of a solid organ in- ing with abdominal pain—a sign with jury, as well as to grade the degree of injury such a broad differential that NSR could and thereby determine the need for surgi- easily be missed during evaluation. Based cal intervention.10 It is worth noting that on its high sensitivity and specificity in in a hemodynamically unstable patient, detecting the presence of free fluid in the exploratory laparotomy may be embarked abdominal cavity, POC ultrasound imag- upon without a CT scan and positive free ing should be used to evaluate patients fluid on ultrasound. presenting with abdominal pain and syncopal or near-syncopal symptoms. This Splenic Injury Scale case further demonstrates that the absence Splenic injury is classified on a scale of 1 of tachycardia or signs of shock should not (mild injury) to 5 (severe injury) (Table).11 rule out NSR.

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